Healthcare Provider Details

I. General information

NPI: 1417959503
Provider Name (Legal Business Name): LORI A REAVES DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 NORTH WHITE HORSE PIKE
HAMMONTON NJ
08037
US

IV. Provider business mailing address

640 NORTH WHITE HORSE PIKE
HAMMONTON NJ
08037
US

V. Phone/Fax

Practice location:
  • Phone: 609-567-9003
  • Fax: 609-567-9269
Mailing address:
  • Phone: 609-567-9003
  • Fax: 858-373-2478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMBO64192
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: